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Which of the following is the best definition of electronic health records?
The portions of a patient's medical records that are stored in a computer system as
well as the functional benefits derived from having an electronic health record
Which of the following statements about electronic health records is true?
The HITECH Act is promoting the widespread adoption of electronic health
Which of the following best defines the termeligible professional?
Anyone who has been granted access to protected health information in electronic
How does point-of-care documentation improve the delivery of the health care
It ensures that all information required for referrals is available immediately.
One drawback of using an EHR on a tablet PC that is not a problem on a
laptop is that it:
lacks a keyboard.
Which of the following is an example of point-of-care documentation?
The physician enters the encounter data during the patient's visit
Which of the following isnot true about an inpatient chart?
Its central element is the physician's exam note.
You are a primary care physician in a small practice. Why do you need to know
about the HITECH Act?
Because it offers you financial incentives for implementing an EHR before 2015
The ONC developed which of the following strategies to meet their goal of
informing clinical practice?
Promoting EHR diffusion in rural and underserved areas
Which of the following first identified capturing data at the point of care as a
key criterion for an EHR?
Computer-based Patient Record Institute (CPRI)
Which of the following is an example of a digital image that may be part of an
electronic medical record?
Text data that is stored in an EHR system isleast useful for performing which of
the following functions?
Which of the following isnot one of the six main categories that the MEDCIN
nomenclature uses to organize findings?
What is the NANDA-I code set used to categorize?
Your medical office is implementing an EHR system and needs to add
numerous paper charts into the new document/image system. The best course
of action would be to:
import the word processing files from any transcribed dictation as text records.
A text file would be produced for upload to an EHR in which of the following
A medical transcriptionist types exam notes using a word processor
An insurance billing code represents a:
service that was rendered
What is a medical protocol?
A standard plan of therapy established for certain conditions
Which of the following wouldnot be considered a benefit of patient-entered data?
The patient can review and make corrections to previous entries made by medical
Which of the following statements about imported text data is false?
The text data is codified by the EHR once it has been imported.
Which of the following is true about the login you use for the Student Edition
It is unique to you.
When using the Student Edition software, what is the first step in every
encounter once you have logged in?
Selecting a patient
The Sx tab on the Nomenclature Pane is associated with which component of
the SOAP format?
You are viewing findings in the Medcin Symptoms tab and notice that "facial
twitching" has neither a small plus sign nor a small negative sign beside it.
What does this mean?
This is the most specific finding available for symptom
What is the main purpose of an EHR system that is based on the MEDCIN
To document clinical notes in a codified electronic medical record
All of the following Entry Details fields are stored in the EHR as fielded data
If you are entering information about tests that have been performed on a
patient, you are most likely to select which tab in the Nomenclature Pane?
Which of the following is the Medcin tab that is used for "treatments"?
Which of the following is the Medcin tab that is used for "tests performed"?
Why is the first item in each drop-down list within the Entry Details fields a
To clear certain Entry Details fields
You are creating a new encounter for the patient Davida Johnson. At what
point do you select "New Encounter" for this patient when using the Student
After you have located and clicked on the patient's name in the Patient Selection
When creating a new patient encounter using the Student Edition software,
where do you enter the chief complaint?
Under what tab in the Student Edition software would you expect to find "
You have entered information about a patient's vital signs using the Vital Signs
form. Where will this information appear on the encounter note?
Which of the following would not be an example of a social history finding
within the Student Edition software?
When you have finished an exercise using the Student Edition software, you
need to output your work to a printer or file, unless instructed otherwise
When printing or exporting encounter notes using the Student Edition software,
remember that you:
should have your printed note or exported file in hand before exiting.
The past medical history for a patient would be most likely to include which of
the following details?
A physician diagnoses a patient with rhinitis and prescribes fluids and rest. To
record this assessment in the Dx tab, where would you begin?
Under which tab is the patient's plan for therapy and treatment recorded?
Why are the Lists and Forms features in an EHR system useful to a clinician
when seeing a patient?
They present the most frequently used findings in one place.
What happens when a physician who is using a list in an EHR system clicks
on the Rx tab to prescribe a medication for her patient?
The list will show a list of the drugs that are typically used to treat the patient's
You work in a pediatrician's office that is implementing an EHR system. Which
of the following conditions is least likely to warrant the creation of a List?
Degenerative joint disease
When using a specific list in the Student Edition software, what would you
expect to see in the left pane of the Sx tab display?
Symptoms related to the patient's chief complaint
When using the Student Edition software, how do you know that ROS grouping
is turned on?
The ROS button is orange
When using the Student Edition software, where do the symptoms you select
when the ROS button is activated appear on the printed encounter note?
Review of Systems
You have selected the Auto Negative button to record a patient's symptoms.
This feature will:
record all previously unselected symptoms related to the patient's condition as
When using a list for a specific condition in an EHR, the Rx tab is least likely to
display which of the following?
An experimental treatment
A patient indicates that he is currently taking no medications except
multivitamins. Where would this information be recorded on the printed
Past medical/surgical history
You are using a form to record information in the Student Edition software, but
want to make sure you have captured everything. Your quickest option would
select Outline View to see all of the findings you have currently selected.
What does the abbreviation CPOE stand for?
Computerized provider order entry
The subcategory of clinical pathology would include which of the following?
A physician determines that her patient needs blood work done. Which of the
following are key components of a "task" within a CPOE system?
Picking up the sample and transporting it to a lab
The Search feature in the Student Edition software:
finds and shows the highest level match for the word that is being searched.
Where will you find the Search feature in the Student Edition software?
The best way to ensure that you will find a word quickly using the Search
feature is to:
spell the word correctly.
Which of the following types of diagnostic images uses the injection of a
radioactive substance called a tracer as part of the imaging process?
Why are radiology reports rarely available as a codified EHR record?
Most radiology reports are still dictated.
A component of a pharmacy computer system that checks for potential
medication dosing errors is known as:
Which of the following statements about a hospital's closed loop of medication
administration is correct?
It helps support the five rights of medication administration.
Which of the following is least likely to require or use a longitudinal patient
Acute care hospital
What is a Problem List?
An up-to-date list of a patient's diagnoses and conditions
Why would a primary care physician choose to add a problem to a patient's
Problem List automatically?
When the physician has already confirmed a diagnosis for the patient
Certain wellness conditions may be included as part of the Problem List based
on which patient information?
You are creating a new encounter for Mrs. Shelly, a longtime patient at your
medical office. When creating the new encounter note for this patient, how
can you compare information from Mrs. Shelly's previous encounters?
By clicking on the Manage tab
In what tab does the Patient Management feature automatically open?
Where does the data that appears in the Med/Surg tab of the Patient
Management section come from?
When using Patient Management, how would a clinician indicate that the
treatment plan for a specific patient problem was working?
The clinician would select Well Controlled from the Problem List tab drop-down
list to record the status.
What does choosing "resolved" for a particular problem do automatically?
It sets appropriate default actions related to that problem.
Before a provider writes a prescription for a patient, he or she should always
Allergies and medications
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